NEW YORK (Reuters Health) – Early tracheotomy placement in critically ill patients is associated with lower ventilator-associated pneumonia (VAP) rates, shorter durations of mechanical ventilation and fewer ICU days, but not with reduced short-term mortality compared to late placement, researchers say.
“We were surprised to see that early tracheotomy – defined as less than or equal to seven days – had an effect on multiple clinical outcomes,” Dr. Alvaro Moreira of University of Texas Health-San Antonio, told Reuters Health by email.
As reported in JAMA Otolaryngology-Head and Neck Surgery, Dr. Moreira and colleagues searched the literature from inception through March 2020 for randomized clinical trials comparing outcomes of early and late tracheotomy.
Seventeen trials (14 at low risk of bias; 3 at moderate-to-high risk) with 3,145 patients (mean age range, 33 to 68) were included in their review.
VAP occurrence decreased among patients undergoing early tracheotomy (OR, 0.59), who also had more ventilator-free days (mean difference, 1.74 days). Early tracheotomy also resulted in fewer ICU days (MD, −6.25 days).
However, mortality was comparable between the early and late groups (OR, 0.66).
Dr. Moreira said, “Our study should stimulate conversations at institutions caring for critically ill adults. Respective leaders should examine their rates of VAP and duration of mechanical ventilation and determine whether an early tracheotomy may improve their current performance.”
“Multiple factors are central to the care of a severely ill adult,” noted, “and the timing of tracheotomy is one component that should be integrated within each institution’s guidelines.”
Dr. Derrick Herman, a pulmonologist at Ohio State University Wexner Medical Center in Columbus commented in an email to Reuters Health, “This study confirms much of the prior research and our clinical experience – tracheostomy reduces the risk of VAP and facilitates liberation from mechanical ventilation.”
“A limitation and concern of this (meta-analysis) is that it combines apples and oranges,” he said. “The studies include multiple different patient populations on mechanical ventilation – trauma, patients with neurological injury, post-surgical patients, and medical patients. Some studies included patients on mechanical ventilation because of pneumonia while others excluded those patients.”
“To be included in many of the studies, the physician had to assess the individual patient as likely requiring mechanical ventilation for greater than seven or 14 days,” he noted. “As a result, these patients had different underlying prognoses, and it is largely the prognosis that informs our decision at the bedside to proceed with tracheostomy.”
“It makes sense to proceed with an early tracheostomy in patients in whom the expected duration of mechanical ventilation will be long,” he said. “Many times, however, it is difficult to prognosticate the length of mechanical ventilation in the beginning, especially for reversible diseases such as pneumonia.”
Further, he added, “There is an unmeasured emotional cost to family and patients in proceeding with a tracheostomy… The decision to pursue a tracheostomy must consider the individual patient, the reason for being on mechanical ventilation, the prognosis, and the patient and family perceptions of a tracheostomy.”
SOURCE: https://bit.ly/3tC7v2x JAMA Otolaryngology-Head and Neck Surgery, online March 11, 2021
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